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EBP/Research Letter of Intent Form

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Date of Letter of Intent Submission:

Name of Proposed Study:

SHORT Name of Proposed Study (50 characters maximum):

Our grants are for nurses doing research or EBP projects in the treatment of patients/families with cancer or auto-immune diseases. What is your proposal for?

How did you learn about the J. Patrick Barnes Grant program?

PROJECT TEAM LEADER

PL - First Name:

PL - Last Name:

PL - Credentials:

PL - Email Address:

PL - Phone Number:

IF THERE ARE ADD'L PEOPLE ON YOUR TEAM - YOU MAY LIST UP TO 5 TOTAL

FIRST Team Member

1 - First Name:

1 - Last Name:

1 - Credentials:

1 - Title:

1 - Email Address:

1 - Phone Number:

1 - Role in Study:

SECOND Team Member

2 - First Name:

2 - Last Name:

2 - Credentials:

2 - Title:

2 - Email Address:

2 - Phone Number:

2 - Role in Study:

THIRD Team Member

3 - First Name:

3 - Last Name:

3 - Credentials:

3 - Title:

3 - Email Address:

3 - Phone Number:

3 - Role in Study:

FOURTH Team Member

4 - First Name:

4 - Last Name:

4 - Credentials:

4 - Title:

4 - Email Address:

4 - Phone Number:

4 - Role in Study:

FIFTH Team Member

5 - First Name:

5 - Last Name:

5 - Credentials:

5 - Title:

5 - Email Address:

5 - Phone Number:

5 - Role in Study:

INSTITUTION INFORMATION

Institution Name:

Street:

City:

State:

Zip Code:

Country

Will the application be for:

EPB Model: Which EBP process model for literature synthesis, translation of your initiative into practice and evaluation of your outcomes will you follow to structure your work? (e.g. Iowa Model, Johns Hopkins Model, or another model in use at your organization)

STUDY PROPOSAL INFORMATION

(To determine the number of words you are using, type in a Word document first and use word count. Then copy/paste into the form below.)

Background: (Maximum 250 words)

Purpose of Study/Description of how this study/project will benefit cancer or auto-immune disease patients and/or family, in keeping with DAISY Foundation's stated goal: (Maximum 200 words)

Would you like the DAISY Foundation to contact you about providing a Mentor?

Do you plan to apply to DAISY for subsequent funding to help you disseminate your findings?

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